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General Santos Doctors’ Medical School Foundation, INC

Bulaong Subdivision, Barangay West, General Santos City, 9500
Tel No.: (083) 302-3507, Telefax No.: (083) 552-9793

Area: Delivery Room - GSDH NCM 109n RLE EXPOSURE Inclusive Dates: April 15-16, 2024

Student’s Name: Keith Bryle Lorilla

Year & Section: BSN 2A

Group: Group 4 A

Biographical Data

Patient’s Full Name: Pt - D.K.B. Marital Status: Married Immunization: Astrazenica – 3 Doses

Age & Sex: 39 – Female Education Level: N/A Allergies: None

Birthdate: March 13, 1985 Occupation: N/A Medications: Oxytocin

Religion: Islam Recent Travel: None Chief Complaint: On and Off fever
for 4 days and rashes for 4 days

Family Health History History of Past Illness History of Present Illness

 Diabetes  Chickenpox  Diabetes

 Asthma  UTI
 Hypertension  Hypertension
 Cephalocaudal Assessment

System Inspection Palpation Percussion Auscultation Other Findings Interpretation

Skin  Skin is brown  Skin is NOT NOT  Skin blanching  Stretchmarks,
in color without smooth. APPLICABLE APPLICABLE and skin turgor healed scars,
presence of  Skin is are less than 2
color normally thin seconds. freckles, moles, or
variations. and is normally birthmarks are
 Skin is intact moisten.
and presence  Skin is warm to common findings.
of reddened touch. Freckles or moles
areas are  Scars were may be scattered
visible. palpated and over the skin in no
 Visible scars are smooth and particular pattern.
were observed. dark and are (Weber & Kelly,
 Macule is >1cm.
2022).
observed 1cm  Skin is mobile  Rough, flaky, dry
in diameter. and recoil is skin is seen in
 Skin is rough, immediate. hypothyroidism.
flaky, and dry.  There is Obese clients
 Edema is edema often report dry
observed. palpated in and itchy skin.
 There both legs and (Weber & Kelly,
are tender 2022)
is presence of upon  Decreased mobility
moles (<0.1 palpation. is seen with
cm) scattered edema. (Weber &
throughout the Kelly, 2022)
extremities.  Scars are a mark
on the body after
an injury, such as
cut that has
healed. (Weber &
Kelly, 2022)
  Scalp is  Hair is NOT NOT NONE  Oiliness may
Hair clean smooth, firm, APPLICABLE APPLICABLE indicate
and oily. and elastic.
 There is poor hygiene in
no which the patient
presence should be given
of proper health
dandruff, education. (Weber
& Kelly, 2022).
lies, and  As people age,
parasites. hair feels coarser
 Hair is and
black drier. The hair is
with a little also
amount of white
hair.
  Hair thinner with
distribution is slower
even. growth. (Weber &
Kelly, 2023).
Nails  Nails are  Nails are hard NOT NOT NONE  If the capillary refill
clean and but and immobile. APPLICABLE APPLICABLE is slow or >2
are untrimmed.  Nails are seconds, it might
 Nail color tone smooth and be an indication of
is pink. firm. respiratory
 Nail is  Pink
attached to or cardiovascular
nailbed. tones returned diseases that
in <2 seconds causes hypoxia.
during capillary (Weber & Kelly,
refill test. 2022).
Head  Head is hard  Temporal NOT NOT NONE  Normocephalic
and smooth artery is elastic APPLICABLE APPLICABLE (literally
without and non-
lesions. tender. translated means
 The face is  There is no 'normal head') is a
symmetrical swelling, medical term
without tenderness, or referring to a
unusual crepitus person whose
movements. palpated in the head and all
 Nasolabial TMJ. major organs of
folds and the head are in a
palpebral normal condition
fissures are
symmetric. and
without

significant
abnormalities.
(AAPC, 2011).
Eyes  The upper lid  Eyeballs NOT NOT NONE  PERRLA is an
is between the APPLICABLE APPLICABLE acronym for “pupils
upper margin are are equal, round
of the iris and symmetrically and reactive to
pupil. aligned light and
without accommodation.”
protruding. Healthcare
 There is no providers
pain upon
palpation.
  The eyelids use the PERRLA
can close eye test to check if
easily by your pupils look
control. and function as
 The eyes have they should.
no inward or (Cleveland Clinic,
outward 2023).
movements.
 There are
no
redness,
discharges,
and lesions.
 Sclera is
smooth and
white.
 The iris is
round and flat.
 PERRLA
 There is
bilateral
constriction of
pupils to light.
Ears  Ears  Auricle, tragus, NOT NOT  Ears are equal in size
are bilaterally and mastoid process APPLICABLE APPLICABLE bilaterally (normally 4-
equal in size (7 cm are firm and non- 10 cm). The auricle
in both). tender. aligns with the corner
 The auricle of each eye and within
aligns with the a 10-degree andle of
corner of each the vertical position.
eye. (Weber & Kelly, 2022)
 The color of
skin

is
consistent with
general skin.
 Neck  Neck is in  Trachea NOT NOT NONE  Muscle spasms,
midline APPLICABLE ASSESSE inflammation, or
position. is midline. D cervical arthritis
 Neck  The landmarks may cause
are positioned
is symmetric midline. stiffness, rigidity,
without  There is no and limited mobility
bulging or tenderness of the neck, which
masses. upon may affect daily
 The movement palpation. functioning.
of neck upon (Weber & Kelly,
swallowing is 20233).
symmetric.
 Patient has a
smooth and
controlled
movement of
the neck.
Thorax & Back  There is no  There is no NOT NOT NONE  Hyperresonance is
nasal flaring palpable ASSESSED ASSESSE elicited in cases of
observed. crepitus. D trapped air, such
 Patient has  The area is free as emphysema
evenly colored from lesions and
skin tone, masses. or pneumothorax.
without (Weber & Kelly,
unusual or 2022).
prominent  The client does not
discoloration use
 Scapulae are
symmetric accessory muscles
and non- to assist breathing.
protruding.
 Shoulders The
are equal. diaphragm is the
 There is no use major muscle
of accessory at
muscles during work. This
breathing. is
 Client is
breathing
effortlessly.
 evidenced

by expansion of
the lower chest
during
inspiration. (Weber
& Kelly, 2022).
Breast  There is no  NOT ASSESSED  NOT  NOT  NOT  Soft, fatty enlargement
swelling, nodules, ASSESSED ASSESSED ASSESSED of breast tissue is seen
or ulcerations in obesity.
detected upon Gynecomastia, a
inspection. smooth, firm, movable
disc of glandular tissue,
may be seen in one
breast in males during
puberty, usually
temporary. However, it
may also be seen in
hormonal imbalances,
drug abuse, cirrhosis,
leukemia, and
thyrotoxicosis.
Irregularly shaped, hard
nodules occur in breast
cancer. (Weber & Kelly,
2022)
Abdomen  Abdomen is flat and   Guarding or  NOT Based on history  Abdominal tenderness
evenly rounded. tensed up ASSESSED taking: is generally a sign of
 Abdomen is response upon  There is inflammation or other
symmetric palpation. no pain acute processes in one
 Umbilicus is midline  No palpable when or more organs. Acute
processes mean
at lateral line masses are touched or
sudden pressure
 Abdomen is free of present pressed. caused by something.
lesions or rashes;  Tendernesss (Healthline, 2022)
skin appears on lower
smooth and but quadrant of the
abdomen.
Genitourinary NOT ASSESSED NOT ASSESSED NOT NOT Based on  Inflammation in the
APPLICABLE APPLICABLE history prostate, or
taking: prostatitis, may
 Pain in the cause painful
abdomen urination and pain
during in the lower
urination. abdomen. The
 History of inflammation may
UTI. spread to ares
 Client is around the
circumcise prostate and cause
d. other symptoms,
such as: lower
back pain and
fever.
(MedicalNewsTod
ay, 2023)
Musculoskel Posture & Gait:  There are no NOT ASSESSED NOT NONE Normal joints: Full ROM
 Patient was swelling palpated in APPLICABLE and no swelling, redness,
et al
unable to walk the upper or tenderness( Weber &
due to labor. extremities.
Kelley, 2018, p. 802 ).
TMJ:
 Mouth opens 1-  Pain when
2in. Opens and  Pain and tenderness of
flexing the lower the
closes smoothly extremities and metatarsophalangeal
 Jaw moves joints are seen in
could not fully
laterally inflammation of the
(protrudes and Flex.
joints, rheumatoid
retracts easily) arthritis, and DJD.
 Jaw has full Tenderness of the
ROM against calcaneus of the
resistance bottom of the foot may
Sternoclavicular joint: indicate plantar
 The fasciitis. It is most
sternoclavicular common cause of heel
pain, which occurs
joint has no when the strong
visible bony supportive band of
overgrowth tissue in the arch of the
foot becomes irritated
Cervical, Thoracic, and
and inflamed. (Mayo
Lumbar Spine: Clinic, 2019b).
 Spine is straight
 Normal ROM
 Can bend 40
degrees to the
left side and 40
degrees to the
right side.
 70 degrees of
rotation
 Full ROM
against
resistance
Shoulders, Arms, and
Elbows:
 Shoulders are
symmetrically
round, no
redness,
swelling,
deformity or
heat.

Elbows:
 Elbows are
symmetric,
without
deformities,
redness, or
 swelling.
 Nontender;
without nodules
 Full ROM
against
resistance
Wrists:
 Wrists are
symmetric,
without redness
or swelling. They
are non-tender
and free of
nodules.
 Squeeze test:
tolerates test
without extreme
pain
 Normal ROM
Hips:
 Straight Leg
Raising: Pain is
reported with
this manuever
 Normal ROM
Ankles & Feet:
 Toes & feet are
in alignment with
the lower leg.
Toes point
forward and lie
flat.
 Normal ROM